After submitting the form and payment below, please allow up to two weeks to receive the medical records.
Authorization for Use and Disclosure of Protected Health Information under HIPAA RULE 164.508
I, {patientsName} with medical record# {medicalRecord} authorize Colon Liver Gastro Consultants to use and disclose in any form or format a copy of records concerning Individual but only as follows, to: {recipientName} for the purpose(s) of {pleaseIndicate}.
I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this Authorization remains effective until the following date: Date (expiration date); the following event: Description of event ; or until you actually receive a signed revocation or until the records retention period required under federal and Name of State law has expired, whichever first occurs; that I have been given an opportunity to ask questions; that I have received a copy of the signed Authorization; that I may inspect a copy of my protected health information to be used or disclosed under this Authorization; that you have not conditioned provision of services to or treatment of me upon receipt of this signed Authorization; and that I may refuse to sign this Authorization. My refusal to sign will not affect my eligibility for benefits or enrollment, payment for or coverage of services, or ability to obtain treatment, except as provided on this form. If the purpose of this Authorization is for the use and/or disclosure of health information for a research study, and I refuse to sign this Authorization, you reserve the right to deny treatment associated with such research. If the purpose of this Authorization is to disclose health information to another party based on health care that is provided solely to obtain such information, and I refuse to sign this Authorization, you reserve the right to deny that health care. I understand that I may inspect or copy the information that is used or disclosed. I understand that I may revoke this Authorization at any time by notifying you in writing, except to the extent that action has been taken in reliance on this Authorization; or if this Authorization is obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
(A copy of this signed form will be provided by the individual patient).
Today's Date: Date*
Printed name of Patient: {patientsName}
In the presence of Witness: First Name Last Name
